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J FOR OFFICE USE: rt APPLICATION FOR SANITATION PERMIT �- -----------------------------------•------------ --- .:� _ (Complete in Triplicate) " Permit No. �� _--_---_-_--_`--------- This Permit Expires 1 Year From Datp.Issued Date Issued ZO_-7�6.4- ., v Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.-- - --- -- ��? 1 +�_ -/�"'�✓ •l}CENSUS TRACT -------------- ----- Owner's Name ------ -- ---Phone ------------------------•� 1 T Address �'i' ��-1c- -------•---------------------- City r . __ /--------------------------------- ---- � _ ---•---- Contractor's Name ----oer,� O-- ------------------------ ---------License Phone d / - Installation will serve. Residence — House Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number ___Number of living units:------ Number of bedrooms _ --__-Garbage Grinder'_� _ Lot Size ,r ------------------------------------- Water -- -------------------Water Supply: Public System and name ------------------------------------ -- -------------'-------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam [] Hardpan 1% Adobe-❑ Fill Material ------------ If yes,type _______________________..__ (Plot plan, showing size of lot, location of system in relation .to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT I ] SEPTIC TANK Size___ e-- --- ---► -=-.----- - Liquid Depth 4441, _o_____________ Capacity/2_f✓-*___ Typep�'O� _ MatericiI6� �1o. Compartments _____________ ! .. Distance to nearest: Well ___ 6_� ____________________Foundation __. --- - Prop. Line _34 . ....... LEACHING LINE 4K No. of Lines __-_ _______________ Length of each line._ �-�__ - Total Length � �� 'D' Box 410-- Type Filter Material, Depth Filter Material --------------_------------------- Distance ___________________Distance to nearest: Well -------------- Foundation - -------------- Property Line. -f___.._ SEEPAGE PIT De th _._ 1 Diameter _ __� _ Number ---- ---------------__ Rock Filled Yes No 0�Q p All 'a Water Table Depth -----___��- ----------------------------Rock Size - -- ---. e -._-.---- -------------------- s � Distance to nearest: Well __ _ `�___ _______________---Foundation ----- Prop. Line ___.___ I REPAIR/ADDITION(Prev. Sanitation Permit# __________________________________________ Date _____________.__________________._) Septic Tank (Specify Requirements) -------------------------------------------------------------------------------------------- ------------------ ------ ' Disposal Field (Specify Requirements) --------------=---------------- - ----------------------------------------------------------------------------------- --- ------ ---------- ---------------------------------------- --------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County: Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the Following: "I certify,thot in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------- ---------- ------ < ---------------------------- Owner ` By ---- (/ Title ------ iGr/[ ----------------- ------------------ (If of r hon owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------- ---------------------------- - DATE ........... .Y -L g•------------------- BUILDING PERMIT ISSUED -------------------------- -----------DATE ---------------------------------- -------- ADDITIONAL COMMENTS ________________ :__________ =:==w-----4----------------------------------------------------- ::__:_____-________-_- ------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ---------- ----- --- -------- ------------- ------------------- ---------- -------=----- -------------------------------------------------- --------------------- = Final Inspection by: --------------'111__ _3 AU tI�-------------------------------------------------------------------------Date --- I6�ix�� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M